Fertility and pregnancy outcomes among women with obstetric fistula in rural Malawi

Identifying opportunities for prevention of adverse outcomes following female genital fistula repair: protocol for a mixed-methods study in Uganda

BACKGROUND

Female genital fistula is a traumatic debilitating injury, frequently caused by prolonged obstructed labor, affecting between 500,000-2 million women in lower-resource settings. Vesicovaginal fistula causes urinary incontinence, and other morbidity may occur during fistula development. Women with fistula are stigmatized, limit social and economic engagement, and experience psychiatric morbidity. Improved surgical access has reduced fistula consequences yet post-repair risks impacting quality of life and well-being include fistula repair breakdown or recurrence and ongoing or changing urine leakage or incontinence. Limited evidence on risk factors contributing to adverse outcomes hinders interventions to mitigate adverse events. This study aims to quantify these adverse risks and inform clinical and counseling interventions to optimize women's health and quality of life following fistula repair through: identifying predictors and characteristics of post-repair fistula breakdown and recurrence (Objective 1) and post-repair incontinence (Objective 2), and to identify feasible and acceptable intervention strategies (Objective 3).

METHODS

This mixed-methods study incorporates a prospective cohort of women with successful vesicovaginal fistula repair at approximately 12 fistula repair centers in Uganda (Objectives 1-2) followed by qualitative inquiry among key stakeholders (Objective 3). Cohort participants will have a baseline visit at the time of surgery followed by data collection at 2 weeks, 6 weeks, 3 months and quarterly thereafter for 3 years. Primary predictors to be evaluated include patient-related factors, fistula-related factors, fistula repair-related factors, and post-repair behaviors and exposures, collected via structured questionnaire at all data collection points. Clinical exams will be conducted at baseline, 2 weeks post-surgery, and for outcome confirmation at symptom development. Primary outcomes are fistula repair breakdown or fistula recurrence and post-repair incontinence. In-depth interviews will be conducted with cohort participants (n ~ 40) and other key stakeholders (~ 40 including family, peers, community members and clinical/social service providers) to inform feasibility and acceptability of recommendations.

DISCUSSION

Participant recruitment is underway. This study is expected to identify key predictors that can directly improve fistula repair and post-repair programs and women's outcomes, optimizing health and quality of life. Furthermore, our study will create a comprehensive longitudinal dataset capable of supporting broad inquiry into post-fistula repair health. Trial Registration ClinicalTrials.gov Identifier: NCT05437939.

Identifying Opportunities for Prevention of Adverse Outcomes Following Female Genital Fistula Repair: Protocol for a Mixed-Methods Study in Uganda

Background

Female genital fistula is a traumatic debilitating injury, frequently caused by prolonged obstructed labor, affecting between 500,000-2 million women in lower-resource settings. Vesicovaginal fistula causes urinary incontinence. Other gynecologic, neurologic and orthopedic morbidity may occur during fistula development. Women with fistula are stigmatized; limit engagement in social, economic, or religious activities; and report high psychiatric morbidity. Improved global surgical access has reduced fistula consequences yet post-repair risks impacting quality of life and well-being include fistula repair breakdown or recurrence and ongoing or changing urine leakage or incontinence. Limited evidence on risk factors contributing to adverse outcomes hinders interventions to mitigate adverse events, protecting health and quality of life after surgery. This study seeks to identify predictors and characteristics of post-repair fistula breakdown and recurrence (Aim 1) and post-repair incontinence (Aim 2), and to identify feasible and acceptable intervention strategies (Aim 3).

Methods

This mixed-methods study incorporates a prospective cohort study of women with successful vesicovaginal fistula repair at approximately 12 fistula repair centers and affiliated care sites in Uganda (Aims 1-2) followed by qualitative inquiry among key stakeholders (Aim 3). Cohort participants will have a baseline visit at the time of surgery followed by data collection at 2 weeks, 6 weeks, 3 months and quarterly thereafter for 3 years. Primary predictors to be evaluated include patient-related factors, fistula-related factors, fistula repair-related factors, and post-repair behaviors and exposures, collected via structured questionnaire at all data collection points. Clinical exams will be conducted at baseline, 2 weeks post-surgery, and for outcome confirmation at symptom development. Primary outcomes are fistula repair breakdown or fistula recurrence and post-repair incontinence. In-depth interviews will be conducted with cohort participants (n ~ 40) and other key stakeholders (~ 40 including family, peers, community members and clinical/social service providers) to develop feasible and acceptable intervention concepts for adjustment of identified risk factors.

Discussion

Participant recruitment is underway. This study is expected to identify key predictors that can directly improve fistula repair and post-repair programs and women's outcomes, optimizing health and quality of life. Furthermore, our study will create a comprehensive longitudinal dataset capable of supporting broad inquiry into post-fistula repair health.

Trial Registration

ClinicalTrials.gov Identifier: NCT05437939.

Factors associated with marital status of women with genital fistula after childbirth: a retrospective review in nine African countries

OBJECTIVE

To examine characteristics associated with remaining married with fistula.

DESIGN

Retrospective record review and logistic regression.

SETTING

Tanzania, Uganda, Kenya, Malawi, Zambia, Rwanda, Ethiopia, Somalia and South Sudan.

PARTICIPANTS

Women who developed fistula during childbirth (1975-2017) and sought treatment (1994-2017).

OUTCOME MEASURE

Self-reported status of living with original husband at time of presentation for fistula repair.

RESULTS

Over half of the women lived with their husbands at the time of fistula treatment (57.2%, 3375/5903). The strongest predictor of remaining married with fistula was either parity at fistula development (adjusted odds ratio [AOR] 1.4-4.4) or living kids at fistula repair (among women who had not given birth between fistula development and repair) (AOR 1.7-4.9). Predicted probability of remaining married declined sharply over the first 2 years of incontinence, levelling out thereafter. Predicted probability of remaining married was lower for women with both urinary and faecal incontinence (AOR 0.68) as compared with women with urinary incontinence alone. Probability of remaining married with fistula declined over time (AOR 1.03-0.57). The woman's education was not a statistically significant predictor, but the odds of remaining married were 26% higher if the husband had any formal schooling.

CONCLUSION

Most husbands do not abandon wives with fistula following childbirth. Treatment, counselling, social support and rehabilitation must consider the circumstances of each woman, engaging men as partners where appropriate. Communities and facilities offering fistula repair services should stress the importance of early intervention.

Social Immersion for Women After Repair for Obstetric Fistula: An Experience in Guinea

Background: Reintegration of women after repair of their female genital fistula remains a challenge. The objective of this study was to document the medical pathway and the reintegration process of women through the “social immersion” program of EngenderHealth in Kissidougou and Labé (Guinea).

Methods: This was a qualitative descriptive study with 55 participants, including women seeking fistula care and stakeholders involved in the social immersion for repaired women in Kissidougou and Labé. The study included collecting demographic and clinical data of women, interviews with women before and after surgery, after social immersion, and 3 months post-discharge. Municipal officials, health providers, and members of host families were also interviewed. The study protocol was approved by the Guinea National Ethics Committee for Health Research.

Results: The study confirmed that obstetric fistula still occurs among women living in rural and underserved areas. Most women attended at least two to five antenatal care visits, but nine over 10 reported a tragic experience of child loss associated with the occurrence of fistula. Most of them received support from their husband/partner during referral after the obstructed labor and later in the search for treatment. Women and stakeholders reported a good experience of surgery and social immersion in both Kissidougou and Labé. About 3 months after discharge, women who were continent reported being happy with their new life compared to women discharged with repair failure and residual incontinence.

Conclusion: The study found the positive impacts of social immersion on the quality of life of women after fistula repair, particularly for those women who had a successful repair. The approach can be included in fistula care programs, either through direct provision or through referral to programs that can provide this service.

Anarcha, Betsey, Lucy, and the women whose names were not recorded: The legacy of J Marion Sims

In April 2018, a statue commemorating J Marion Sims was removed from Central Park, New York, and relocated to Green-Wood Cemetery in Brooklyn, where he is buried. In 1849, Sims developed a repeatable surgical solution for obstetric fistula, a debilitating condition caused by prolonged, obstructed labour, which damages the vaginal wall, resulting in permanent leakage via the vagina from either the bowel or bladder and sometimes both. Initially, Sims appears worthy of widespread adulation. There are several commemorative statues of him, he has been afforded the title of the 'father of modern gynaecology', and for 37 years, the American Urogynecological Society held an annual eponymous lecture, among other honours. Obstetric fistula rendered women social pariahs, unable to engage fully in either domestic or public life. Sims was able to create a reliably repeatable surgical solution but did so through ongoing experimentation on enslaved women. One of these women, Anarcha, was operated on at least 30 times without the use of anaesthesia over a four-year period, despite the availability of anaesthesia for the majority of the experimentation period. Over 170 years later, Sims' story retains its relevance because it represents a clear point at which race, gender and class intersect with medicine. This paper will use Sims' own account to drive the narrative, then examine matters of agency, ethics and consent that come from it, to show that his work, and subsequent renown, were only possible because of the inherent violence of chattel slavery and other systemic forms of oppression.

Reintegration needs of young women following genitourinary fistula surgery in Uganda

INTRODUCTION AND HYPOTHESIS

Genitourinary fistulas (usually arising following prolonged obstructed labor) are particularly devastating for women in low-income counties. Surgical repair is often difficult and delayed. While much attention has been devoted to technical surgical issues, the challenges of returning to normal personal, family, and community life after surgical treatment have received less scrutiny from researchers. We surveyed young Ugandan women recovering from genitourinary fistula surgery to assess their social reintegration needs following surgery.

METHODS

A cross-sectional survey of 61 young women aged 14-24 years was carried out 6 months postoperatively. Interviews were carried out in local languages using a standardized, interviewer-administered, semistructured questionnaire. Data were entered using EpiData and analyzed using SPSS.

RESULTS

Ongoing reintegration needs fell into interrelated medical, economic, and psychosocial domains. Although >90% of fistulas were closed successfully, more than half of women had medical comorbidities requiring ongoing treatment. Physical limitations, such as foot drop and pelvic muscle dysfunction impacted their ability to work and resume their marital relationships. Anxieties about living arrangements, income, physical strength, future fertility, spouse/partner fidelity and support, and possible economic exploitation were common. Sexual dysfunction after surgery-including dyspareunia, loss of libido, fear of intercourse, and anxieties about the outcome of future pregnancies-negatively impacted women's relationships and self-esteem.

CONCLUSIONS

Young women recovering from genitourinary fistula surgery require individualized assessment of their social reintegration needs. Postoperative social reintegration services must be strengthened to do this effectively.

Pelvic Ultrasound Findings in Women with Obstetric Fistula: A Cross-Sectional Study of Cases and Controls

Objective

Obstetric fistula (OF) is a morbid condition caused by prolonged obstructed labor. Women with OF experience profound injury and have high rates of infertility and poor obstetric outcomes. We examined endovaginal ultrasound parameters in women with and without OF.

Design/Setting/Sample/Methods

This cross-sectional study enrolled women evaluated at the Fistula Care Centre in Lilongwe, Malawi. Eligibility criteria included age 18–45, prior pregnancy, and a uterus on ultrasound. Participants underwent endovaginal ultrasound with measurement of cervical dimensions. Comparisons were done using t-tests and Fisher's exact test. Among women with OF, linear regression was used to assess whether fistula stage was associated with cervical length.

Results

We enrolled 98 cases and 12 controls. Women with OF had shorter cervical lengths (18.8 mm versus 27.3 mm, p < 0.01), as well as shorter anterior (7.0 mm versus 9.3 mm, p < 0.01) and posterior (9.5 mm versus 11.0 mm, p < 0.04) cervical stroma, compared to controls.

Conclusion

Women with OF have shorter cervical lengths and anterior and posterior cervical stroma, when compared to women without OF. This may offer a partial explanation for subfertility and poor obstetric outcomes in OF patients. Additional studies to clarify the role of ultrasound in OF patients and prediction of future fertility are warranted.

Fertility outcomes following obstetric fistula repair: a prospective cohort study

BACKGROUND

Obstetric fistula (OF) is a maternal morbidity associated with high rates of stillbirth, amenorrhea, and sexual dysfunction. Limited data exists on the reproductive outcomes of women in the years following a fistula repair. The objective of this study is to describe the fertility outcomes and family planning practices in a population of Malawian women 1-4 years after fistula repair.

METHODS

Women who had enrolled into a clinical database of OF patients and undergone OF repair between January 1, 2012 and July 31, 2014 were recruited and enrolled to complete a home-based survey of their demographic and reproductive health data 1-4 years after their repair. Pregnancy, amenorrhea, and sexual function were described using frequency analysis, and we compared antimüllerian hormone (AMH) concentrations between women with menses or pregnancy with women with amenorrhea or no pregnancy using Wilcoxon rank sum tests.

RESULTS

Of 297 women with a prior OF repair, 148 had reproductive potential and were included in this analysis. Overall 30 women of these women (21%) became pregnant since their fistula repair, with most pregnancies ending with cesarean delivery. Of the 32 women who were amenorrheic at the time of repair, 25 (78.1%) had resumption of menses. Only 11 (8.6%) of sexually active women reported dyspareunia, and among women who were not trying to conceive, 53.1% were currently using a method of family planning. No significant differences were found in AMH concentrations between those who were pregnant or had menses versus those without pregnancy or menses, respectively.

CONCLUSIONS

In this long-term follow-up study of women after OF repair, many women were able to achieve a pregnancy with a live birth, have normal menses, be sexually active, and access contraception. These achievements will further assist a population of women whose reintegration and restoration of dignity is closely tied to their ability to achieve their reproductive goals.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02685878 .

The association between female genital fistula symptoms and gender-based violence: A multicountry secondary analysis of household survey data

OBJECTIVE

The Demographic and Health Surveys (DHS), which include standardised questions on female genital fistula symptoms, provide a unique opportunity to evaluate the epidemiology of fistula. This study sought to examine associations between self-reported fistula symptoms and experience of gender-based violence (GBV) among women interviewed in DHS surveys.

METHODS

This study used data from thirteen DHS surveys with standardised fistula and domestic violence modules. Data from the most recent survey in each country were pooled, weighting each survey equally. Multivariable logistic regressions controlled for maternal and demographic factors.

RESULTS

Prevalence of fistula symptoms in this sample of 95 625 women ranges from 0.3% to 1.8% by country. The majority of women reporting fistula symptoms (56%) have ever experienced physical violence, and more than one-quarter have ever experienced sexual violence (27%), compared with 38% and 13% among women with no symptoms, respectively. Similarly, 16% of women with fistula symptoms report recently experiencing sexual violence-twice the percentage among women not reporting symptoms (8%). Women whose first experience of sexual violence was from a non-partner have almost four times the odds of reporting fistula symptoms compared with women who never experienced sexual violence. These associations indicate a need to investigate temporal and causal relationships between violence and fistula.

CONCLUSIONS

The increased risk of physical and sexual violence among women with fistula symptoms suggests that fistula programmes should incorporate GBV into provider training and services.

Fistula recurrence, pregnancy, and childbirth following successful closure of female genital fistula in Guinea: a longitudinal study

Background

Female genital fistula is a devastating maternal complication of delivery in developing countries. We sought to analyse the incidence and proportion of fistula recurrence, residual urinary incontinence, and pregnancy after successful fistula closure in Guinea, and describe the delivery-associated maternal and child health outcomes.

Methods

We did a longitudinal study in women discharged with a closed fistula from three repair hospitals supported by EngenderHealth in Guinea. We recruited women retrospectively (via medical record review) and prospectively at hospital discharge. We used Kaplan-Meier methods to analyse the cumulative incidence, incidence proportion, and incidence ratio of fistula recurrence, associated outcomes, and pregnancy after successful fistula closure. The primary outcome was recurrence of fistula following discharge from repair hospital in all eligible women who consented to inclusion and could provide follow-up data.

Findings

481 women eligible for analysis were identified retrospectively (from Jan 1, 2012, to Dec 31, 2014; 348 women) or prospectively (Jan 1 to June 20, 2015; 133 women), and followed up until June 30, 2016. Median follow-up was 28·0 months (IQR 14·6–36·6). 73 recurrent fistulas occurred, corresponding to a cumulative incidence of 71 per 1000 person-years (95% CI 56·5–89·3) and an incidence proportion of 18·4% (14·8–22·8). In 447 women who were continent at hospital discharge, we recorded 24 cases of post-repair residual urinary incontinence, equivalent to a cumulative incidence of 23·1 per 1000 person-years (14·0–36·2), and corresponding to 10·3% (5·2–19·6). In 305 women at risk of pregnancy, the cumulative incidence of pregnancy was 106·0 per 1000 person-years, corresponding to 28·4% (22·8–35·0) of these women. Of 50 women who had delivered by the time of follow-up, only nine delivered by elective caesarean section. There were 12 stillbirths, seven delivery-related fistula recurrences, and one maternal death.

Interpretation

Recurrence of female genital fistula and adverse pregnancy-related maternal and child health outcomes were frequent in women after fistula repair in Guinea. Interventions are needed to safeguard the health of women after fistula repair.

Funding

Belgian Development Cooperation (DGD), Institute of Tropical Medicine of Antwerp (ITM), and Maferinyah Training and Research Center in Rural Health (Guinea).

Relying on Visiting Foreign Doctors for Fistula Repair: The Profile of Women Attending Fistula Repair Surgery in Somalia

Obstetric fistula is treatable by surgery, although access is usually limited, particularly in the context of conflict. This study examines the profile of women attending fistula repair surgery in three hospitals in Somalia. A cross-sectional study was conducted in Somalia from August to September 2016. Structured questionnaires were administered to 81 women who registered for fistula repair surgery in the Garowe, Daynile, and Kismayo General Hospitals in Somalia. Findings revealed that 70.4% of the study participants reported obstetric labor as the cause of their fistula, and 29.6% reported iatrogenic causes. Regarding the waiting time for the repair surgery, 45% waited for the surgery for over one year, while the rest received the surgery within a year. The study suggests that training for fistula surgery has to be provided for healthcare professionals in Somalia, fistula centers should be established, and access to these facilities has to be guaranteed for all patients who need these services.

A descriptive longitudinal study protocol: recurrence and pregnancy post-repair of obstetric fistula in Guinea

Background

Obstetric fistula is a serious medical condition which affects women in low income countries. Despite the progress of research on fistula, there is little data on long term follow-up after surgical repair. The objective of this study is to analyse the factors associated with the recurrence of fistula and the outcomes of pregnancy following fistula repair in Guinea.

Methods

A descriptive longitudinal study design will be used. The study will include women who underwent fistula repair between 2012 and 2015 at 3 fistula repair sites supported by the Fistula Care Project in Guinea (Kissidougou Prefectoral Hospital, Labé Regional Hospital and Jean Paul II Hospital of Conakry).

Participants giving an informed consent after a home visit by the Fistula Counsellors will be interviewed for enrolment at least 3 months after hospital discharge The study enrolment period is January 1, 2012 − June 30, 2015. Participants will be followed-up until June 30, 2016 for a maximum follow up period of 48 months. The sample size is estimated at 364 women.

The cumulative incidence rates of fistula recurrence and pregnancy post-repair will be calculated using Kaplan-Meier methods and the risk factor analyses will be performed using adjusted Cox regression. The outcomes of pregnancy will be analysed using proportions, the Pearson’s Chi Square (χ2) and a logistic regression with associations reported as risk ratios with 95 % confidence intervals. All analyses will be done using STATA version 13 (STATA Corporation, College Station, TX, USA) with a level of significance set at P < 0.05.

Discussion

This study will contribute to improving the prevention and management of obstetric fistula within the community and support advocacy efforts for the social reintegration of fistula patients into their communities. It will also guide policy makers and strategic planning for fistula programs.

Trial registration

ClinicalTrials.gov Identifier: NCT02686957. Registered 12 February 2016 (Retrospectively registered).

Pregnancy and childbirth after repair of obstetric fistula in sub-Saharan Africa: Scoping Review

OBJECTIVE

To synthesise the evidence on pregnancy and childbirth after repair of obstetric fistula in sub-Saharan Africa and to identify the existing knowledge gaps.

METHODS

A scoping review of studies reporting on pregnancy and childbirth in women who underwent repair for obstetric fistula in sub-Saharan Africa was conducted. We searched relevant articles published between 1 January 1970 and 31 March 2016, without methodological or language restrictions, in electronic databases, general Internet sources and grey literature.

RESULTS

A total of 16 studies were included in the narrative synthesis. The findings indicate that many women in sub-Saharan Africa still desire to become pregnant after the repair of their obstetric fistula. The overall proportion of pregnancies after repair estimated in 11 studies was 17.4% (ranging from 2.5% to 40%). Among the 459 deliveries for which the mode of delivery was reported, 208 women (45.3%) delivered by elective caesarean section (CS), 176 women (38.4%) by emergency CS and 75 women (16.3%) by vaginal delivery. Recurrence of fistula was a common maternal complication in included studies while abortions/miscarriage, stillbirths and neonatal deaths were frequent foetal consequences. Vaginal delivery and emergency C-section were associated with increased risk of stillbirth, recurrence of the fistula or even maternal death.

CONCLUSION

Women who get pregnant after repair of obstetric fistula carry a high risk for pregnancy complications. However, the current evidence does not provide precise estimates of the incidence of pregnancy and pregnancy outcomes post-repair. Therefore, studies clearly assessing these outcomes with the appropriate study designs are needed.

Living with constant leaking of urine and odour: thematic analysis of socio-cultural experiences of women affected by obstetric fistula in rural Tanzania

Background

Obstetric fistula is a worldwide problem that affects women and girls mostly in Sub Saharan Africa. It is a devastating medical condition consisting of an abnormal opening between the vagina and the bladder or rectum, resulting from unrelieved obstructed labour. Obstetric fistula has devastating social, economic and psychological effect on the health and wellbeing of the women living with it. This study aimed at exploring social-cultural experiences of women living with obstetric fistula in rural Tanzania.

Methods

Women living with obstetric fistula were identified from the fistula ward at CCBRT hospital. Sixteen individual semi structured interviews and two (2) focus group discussions were conducted among consenting women. Interviews were transcribed verbatim and transcripts analysed independently by two researchers using a thematic analysis approach. Themes related to the experiences of living with obstetric fistula were identified.

Results

Four themes illustrating the socio-cultural experiences of women living with obstetric fistula emerged from the analysis of women experiences of living with incontinence and odour. These were keeping clean and neat, earning an income, maintaining marriage, and keeping association. Women experiences of living with fistula were largely influenced by perceptions of people around them basing on their cultural understanding of a woman.

Conclusion

Living with fistula reveals women’s day-to-day experiences of social discrimination and loss of control due to incontinence and odour. They cannot work and contribute to the family income, cannot satisfy their husband’s sexual needs and or bear children, and cannot interact with members of the community in social activities. Women experience of living with fistula was influenced by perceptions of people around them. In the eyes of these people, women who leak urine were of less value since they were not capable of carrying out ascribed social roles.

Urogenital fistula reviewed: a marker of severe maternal morbidity and an indicator of the quality of maternal healthcare delivery

BACKGROUND

While obstetric fistula has been recognized as a major maternal morbidity since the 1980s, it has become an indicator of access to and quality of women' s health care.

FINDINGS

Obstetric fistula still exists in low-income countries (LIC) because health care systems fail to provide adequate family planning, skilled birth attendance, basic and emergency obstetric care, and affordable treatment of fistula, while concurrently lacking social networks to serve as safety nets for affected girls and women [WHO, 2007].

CONCLUSION

This review explores the most recent published experience with respect to the definition of fistula, its diagnosis, treatment, and management, and further steps for prevention of fistula on a global scale.

Factors associated with loss to follow-up in women undergoing repair for obstetric fistula in Guinea

OBJECTIVES

To analyse the trend of loss to follow-up over time and identify factors associated with women being lost to follow-up after discharge in three fistula repair hospitals in Guinea.

METHODS

This retrospective cohort study used data extracted from medical records of fistula repairs conducted from 1 January 2007 to 30 September 2013. A woman was considered lost to follow-up if she did not return within 4 months post-discharge. Factors associated with loss to follow-up were identified using a subsample of the data covering the period 2010-2013.

RESULTS

Over the study period, the proportion of loss to follow-up was 21.5% (448/2080) and varied across repair hospitals and over time with an increase from 2% in 2009 to 52% in 2013. After adjusting for other variables in a multivariate logistic regression model, women who underwent surgery at Labe hospital and at Kissidougou hospital were more likely to be lost to follow-up than women operated at Jean Paul II hospital (OR: 50.6; 95% CI: 24.9-102.8) and (OR: 11.5; 95% CI: 6.1-22.0), respectively. Women with their fistula closed at hospital discharge (OR: 3.2; 95% CI: 2.1-4.8) and women admitted for repair in years 2011-2013 showed higher loss to follow-up as compared to 2010. Finally, loss to follow-up increased by 2‰ for each additional kilometre of distance a client lived from the repair hospital (OR: 1.002; 95% CI: 1.001-1.003).

CONCLUSION

Reimbursement of transport was the likely reason for change over time of LTFU. Reducing geographical barriers to care for women with fistula could sustain fistula care positive outcomes.

"Hoping for a normal life again": reintegration after fistula repair in rural Tanzania

OBJECTIVE

To explore women's expectations, worries, and hopes related to returning to their family and community after fistula repair.

METHODS

We used a concurrent mixed methods design with a hospital survey and qualitative interviews. One hundred fifty-one women completed a questionnaire, eight were interviewed in hospital after fistula repair, and one woman was followed up at home for six months during the reintegration phase.

RESULTS

Women were concerned about where they could live and about not being accepted by their husbands and in-laws. While 51% feared that their husbands would not accept them despite full recovery, 53% said their parents would accept them. In the qualitative study women wished to live with their parents, whereas almost one half (49.7%) of the women in the quantitative study, who had lived with fistula for a shorter time, wished to live with their husbands. All women hoped to have children in the future, although many women, especially those with no children, were worried about whether they could bear children in the future. Despite fears related to economic survival and social acceptance, women were optimistic about regaining a normal social life.

CONCLUSION

Women's expectations of going home after fistula repair are linked to their history of living with obstetric fistula. For women who have lived with a fistula for many years, reintegration involves re-establishing an identity that is clean and respected. To facilitate this transition, fistula repair needs to be accompanied by psychological and social rehabilitation and assistance in returning to reproductive capabilities.

Outcomes in obstetric fistula care: a literature review

PURPOSE OF REVIEW

To highlight the lack of consistency in the terminology and indicators related to obstetric fistula care and to put forward a call for consensus.

RECENT FINDINGS

Recent studies show at least some degree of statistical correlation between outcome and the following clinical factors: degree of scarring/fibrosis, fistula location, fistula size, damage to the urethra, presence of circumferential fistula, bladder capacity, and prior attempt at fistula repair.

SUMMARY

Consensus about basic definitions of clinical success does not yet exist. Opinions vary widely about the prognostic parameters for success or failure. Commonly agreed upon definitions and outcome measures will help ensure that site reviews are accurate and conducted fairly. To properly compare technical innovations with existing methods, agreement must be reached on definitions of success. Standardized indicators for mortality and morbidity associated with fistula repair will improve the evidence base and contribute to quality of care.

Factors associated with the utilization of maternal health care services among adolescent women in Malawi

The poor maternal health care service utilization among adolescent women remains an intimidating challenge in Malawi. This study examines the factors associated with the utilization of selected maternal health care services among married adolescent women (aged 15-19 years) using data from the Malawi Demographic and Health Survey, 2010. Maternal age, household economic status, and status of the child were found to be significant factors associated with at least four antenatal care visits; whereas personal barriers, birth order and interval, religion, and ethnic group explain the variation in the utilization of postnatal care within 42 days of delivery.

Medico-social pathways of obstetric fistula patients in Mali and Niger: an 18-month cohort follow-up

OBJECTIVES

To gain understanding of care pathways and induced mobility patterns of obstetric fistula patients in French-speaking West African fistula repair centres.

METHODS

We followed prospectively during 18 months a cohort of obstetric fistula patients in Mali and Niger (2008-2009). 120 patients were recruited at different stages of their care process in 5 reference fistula repair centres. Follow-up was carried out in repair centres and communities. Quantitative data were collected through close-ended questionnaires at three time points. Medico-social pathways were explored through a longitudinal analysis focusing on six indicators: fistula duration, care process duration, patients' mobility, marital status, number of surgeries and continence status.

RESULTS

Patients' pathways were characterised by their length: fistula duration (median 4 years), care process duration (median 2.7 years), aggregated time spent in repair centres during study (median 7 months). Patients developed four mobility patterns (homebound, itinerant, institutionalised and urbanised). Adverse marital status change continued over time. Sample stratification according to number of previous surgeries revealed differences in care process duration and outcome: 23/31 new cases (≤1 surgery) gained continence with a mean of 1.5 surgeries in a median of 0.6 year while only 17/78 old cases (≥2 surgeries) became continent with a mean of 4 surgeries in a median time of 4.9 years.

CONCLUSION

The quest for continence does not end with admission to a fistula repair centre. Analysing fistula care experience across time within the varying settings highlights the twofold population and mixed medico-social outcomes that should prompt new development in obstetric fistula care management and research.